Assessing A Case Of Chronic Metatarsal Pain

Recently, a patient took the time to write all the way from Italy, wondering if I could shed some light on a foot issue he’d been struggling with for five years. He is 33 years old, 6' 4'' tall and weighs 165 pounds. The patient initially noted pain after suffering a minor injury, which caused capsulitis on his right first MPJ. While the capsulitis eventually resolved, he gradually started to experience new discomfort with the same foot. He attributed this new pain, which he had for a couple of months, to the metatarsal pad on his orthotics but only had this pain on the right foot. 

After switching to a pair of orthotics without the metatarsal pads, the patient said the discomfort shifted to other areas of the forefoot and always seemed to occur when propelling in gait. He also describes an unpleasant sensation of “feeling” his metatarsals when walking. Fed up with the orthotics, he stopped using them. After a few days of walking pain-free, he thought the condition had finally resolved but the old symptoms returned in a short period of time.

The patient saw a podiatrist, who felt his discomfort was due to unilateral overpronation and recommended semi-rigid orthotics. This helped for a few days but the symptoms returned once again. Even after implementation of more rigid devices, the patient had the same recurrence of symptoms. Additionally, the treating podiatrist noted some asymmetrical calf weakness. The patient began a home exercise program and subsequently presented to a physical therapist.

The physical therapist noticed a number of compensation patterns on the affected side, mainly internal rotation of the leg, pelvic tilt, overactivity of the tibialis anterior, and compensation involving the latissimus dorsi, which was working harder than normal on the affected side to maintain balance. The patient had five physical therapy sessions, which included manual manipulation. After minimal improvement, he was again referred to podiatry to rule out “intrinsic foot problems.”

My initial advice to the inquiring patient at this point is that all of his symptoms could be related to his unilateral overpronation. I do not feel his symptoms are related to the original capsulitis. My suspicions were confirmed when the patient shared that his next podiatry evaluation revealed ligamentous laxity, loss of forefoot fat pad and an 11 millimeter limb length discrepancy with the affected side being longer. My approach to such a situation is to gradually build up the shorter side over time. When you correct only for the unilateral pronation, the orthotic on that side will force the hip to be higher. Since it is the longer side already, this correction will magnify it, making you have to put even more lifts on the short side. Your choice will be this direction, or symmetrical orthotics only and the lift on the short side which may be simple and corrective enough.

I reassured the patient that an injury can cause biomechanical stresses (compensations, tight or weak muscles, etc) to manifest for the first time causing other pains.This could be due to deconditioning from the injury or compensation from the injury, but I do find these symptoms to be very common. I joke to my patients that at least the pain syndrome that has developed usually stops after the third area begins to hurt and sometimes they get my humor. I also account for the tightness in the Achilles tendon that often develops, causing additional stress to the injured foot and limb.

I additionally recommend a shoe with a flexible forefoot as the patient noted some relief in the forefoot when walking barefoot. He would benefit from a lower extremity neurological examination as he pointed out that X-rays and magnetic resonance imaging (MRI) have all been “clean.” Variability in his symptoms appears to result from more of a stress syndrome than an injury. I recommended that he change the mechanics, do strengthening exercises with single leg balancing and metatarsal doming, and stretch the Achilles tendons several times a day. At least ¼ inch full-length lifts could be helpful for this patient.

Approximately six weeks later, the patient in question provided some follow up. He felts his gait had improved with a 5 millimeter heel lift (not full-length) on the shorter leg. He noted more ease in propulsion with a less rigid device. While he noted improvement with some symptom relief, the patient said his symptoms had not completely resolved. The patient is still attending physical therapy sessions. 

At his next podiatric appointment, my thoughts are he may benefit from experimenting with another orthotic device for the short side, without the lift attached, but with two 1/8 inch, full-length, soft material lifts. One lift could be full-length and one lift could be cut at the sulcus. I feel this could add cushion, but not pitch him forward as much onto the metatarsals. 

The patient additionally noted that he may be unevenly bearing weight when he walks. I encouraged him to look at old inserts, ones that had been worn a while, to see if one side is broken down more. An alternative method could be to stand evenly on two bathroom scales. When standing with equal weight in his mind, someone else could read the scales to measure. As soon as he would look down to read the scales, the technique would not work. Since he likely does not have access to a sophisticated force plate or mat, this could still be helpful. 

The patient related that he had multiple pedobarographic analyses that seemed to rule out any asymmetrical weightbearing. Most researchers, however, feel one must walk over a force plate ten or more times to even begin to practice the landing. Force plate analysis in an office setting poses challenges for this reason unless the test is done multiple times and a definite pattern emerges. For these reasons, I have not purchased such a system for my office at this time although I do understand the value of pedobarographic analysisin many situations.

Interestingly, as a follow up to my recommendation for a neurological exam, the patient now relates a mild burning sensation along the course of the hallux. He experiences this when moving his leg after a period of inactivity, usually after sitting or lying down. He notes this burning sensation also occurs when sitting down after a walk. This is classic L4 nerve root irritation. The patient does seem to have some minor nerve problem, possible contributing to a “double crush” syndrome. I recommend that he be evaluated for this so the treating clinician can address this nerve issue as well as his biomechanical issues. Hopefully, this will address the patient’s concerns in a comprehensive and personalized way. 

Dr. Blake is in practice at the Center for Sports Medicine affiliated with St. Francis Memorial Hospital in San Francisco. He is a past president of the American Academy of Podiatric Sports Medicine.

Editor’s note: This blog originally appeared at https://www.drblakeshealingsole.com/2019/06/chronic-metatarsal-pain-email-advice.html. It is adapted with permission from the author.